Policy Compliance Procedure

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1 Policy Compliance Procedure Safe Handling of Adult Intravenous Potassium Chloride Preparations This PCP relates to NSW Health PD NSW Health Policy Directive PD2005_342 Safe Handling of Intravenous Potassium Chloride in Health Care Facilities PCP number PD2005_342:PCP 2 All Hunter New England Health (HNE Health) hospitals in noncritical care areas Sites where PCP applies Target audience All non-critical care area clinicians who prescribe for, or administer intravenous (IV) potassium chloride to ADULTS Description Provides evidence based guidance for the storage, prescribing and administration of IV potassium chloride to adults in noncritical care areas Safe handling of IV potassium for use in adult non-critical Subject care area facilities Keywords intravenous, potassium chloride, concentrated potassium salts, adult Replaces Existing PCP? Yes PD2005_342:PCP 2 Version One frome17 June 2010 and Numbers of superseded documents Version Two from 16 August 2012 Related Legislation (including OHS legislation), Australian Standards, NSW Health Policy or Circular, other HNEH Documents, Professional Guidelines, Codes of Practice or Ethics: NSW Health Policy Directive PD2005_342 Policy on the Safe Handling of Intravenous Potassium Chloride in Health Care Facilities Medication Alert Intravenous Potassium Chloride Australian Council for Safety and Quality in Health Care, October Portfolio Executive Director Todd McEwan, Director, Acute Networks responsible for Policy and PCP Policy Contact Person HNE Director of Pharmacy Contact Details Summary Outlines the requirements for the safe storage, prescribing and administration of intravenous (IV) potassium chloride Similar requirements need to be applied for other concentrated salts (e.g. potassium acetate and potassium dihydrogen phosphate) which are not routinely held by all HNE Health sites Will assist with the correction of hypokalaemia and maintenance of potassium requirements where oral potassium supplements are unsuitable Distribution: Date PCP authorised: 23 April 2013 PCP authorised by: Todd McEwan, Director Acute Networks Date of Issue: 24 April 2013 PCP Review Due Date: 24 April 2016 TRIM Number: 13/ Version Three April 2013

2 Background Safe Handling of Adult Intravenous Potassium Chloride Preparations PD2005_342:PCP2 In 2003, the Australian Council for Safety and Quality in Health Care (now the Australian Commission on Safety and Quality in Healthcare) noted that concentrated potassium chloride had been implicated in fatalities in Australia and overseas and urged that concentrated potassium chloride be removed from general patient care areas on a consistent and national basis. As a result, the Medication Safety Taskforce of the Australian Council for Safety and Quality in Health Care issued a Medication Alert entitled Intravenous POTASSIUM CHLORIDE can be fatal if given inappropriately. The above mentioned Alert was provided for the attention of relevant area health service personnel, including pharmacists, medical officers, nurses and supply personnel and noted that... critical incidents have been associated with the preparation and administration of intravenous (IV) potassium chloride indicating that patients are at risk. The Medication Alert can be found at: File/kcalertfinal1.pdf) In NSW and nationally, concentrated potassium chloride (along with other concentrated potassium salts) is considered a high risk medication. High risk medicines are those that have a high risk of causing injury or harm if they are misused or used in error. Error rates with these medications are not necessarily higher than with any other medicines, but when problems occur, the consequences can result in serious or catastrophic harm to patients. Internationally, many safety organisations recommend that hospitals and health services identify the high risk medications that they use through review of incident data and published information. It is important that action is then taken to reduce the risk of harm associated with these agents. HNE Health has adopted the NSW Health list of high risk medications for local use. This list and more information on high risk medications can be found at: In relation to the use of intravenous potassium chloride in NSW, three types of error associated with the preparation and administration of intravenous potassium chloride have been identified. These include: Wrong ampoule (eg potassium chloride ampoule selected instead of sodium chloride 0.9 % due to similar appearance); Cognitive mix-up (familiar pairing of potassium chloride with another drug, such as frusemide); Preparation error (incorrect preparation of an IV infusion of potassium chloride). In addition,... the availability of potassium chloride ampoules as stock in ward areas has been identified as the common root cause of these errors. Hence, NSW Health released its Policy Directive (PD2005_342) indicating that hospitals MUST implement safety controls, advising that: concentrated potassium chloride ampoules are to be removed from ward stock and replaced with standard premixed solutions for intravenous infusion, wherever possible, and ampoules of other concentrated potassium salts (eg potassium dihydrogen phosphate) should also be removed from ward stock. (NSW Health Policy Directive PD2005_342 Policy on the Safe Handling of Intravenous Potassium Chloride in Health Care Facilities at: ) Version Three April 2013 Page 2

3 1. PROCEDURES In order to adhere to NSW Health policy recommendations, the following procedures have been developed for HNE Health facilities: 1.1 Storage and availability of parenteral potassium solutions Storage in designated areas: Concentrated potassium chloride ampoules (10 mmol in 10 ml) are not to be kept as ward stock in general adult wards. If ampoules are kept in critical care areas, they must be stored securely separate from other ampoules in an area labelled Hypertonic Solutions or similar. Premix IV bags containing various amounts of potassium chloride in infusion fluid (see Appendix 1) are stocked on imprest in most clinical / ward areas within HNE Health hospitals. These solutions are easily distinguished from other IV fluids as they are packaged in a pink outer bag with labeling in red writing. 1.2 Prescribing potassium Requests / orders for intravenous potassium that do not meet these guidelines must be authorised by the treating consultant or an ICU / ED consultant. Oral potassium supplements should be used for the management of mild to moderate hypokalaemia whenever possible. These guidelines are evidence based and if a physician chooses to prescribe outside HNE Health Guidelines they must document in the patient notes the reason(s) why they have done so. When prescribing intravenous potassium chloride: Use the IV fluid treatment chart Prescribe using a standard IV premix solution whenever possible o When prescribing potassium for IV use, it is safer to prescribe a premix solution than use ampoules added to an infusion bag. Refer to Appendix 1 for premix solutions containing potassium. Include: o Strength in millimole/litre (mmol/l) / infusion volume The maximum concentration for potassium administration on a general ward must not exceed 40 mmol/l without registrar/consultant approval except when using the 10 mmol potassium chloride in sodium chloride 0.29 % 100mL which is isotonic. This is because prolonged administration of hypertonic potassium solutions of > 40 mmol/l through a peripheral line may cause phlebitis. o Rate in millimoles/hour (mmol/h) The maximum infusion rate for intravenous potassium administration on a general ward must not exceed 20 mmol/h. If prescribing more than 10 mmol/h a senior medical officer MUST be involved and ECG monitoring is mandatory. If administered too quickly there is a high risk of cardiac arrest. o Infusion fluid (e.g. sodium chloride 0.9 %, glucose 5 % or glucose / sodium chloride 4 % / 0.18 %) Version Three April 2013 Page 3

4 What to avoid: o Do NOT use chemical symbols e.g. KCl. Orders written in this way are invalid. o Potassium salts must never be given IM or as an IV push (bolus). The word bolus must NEVER be used for IV potassium solution orders. Potassium must only be given as a slow infusion. Alternative concentrated potassium salts such as potassium acetate and potassium dihydrogen phosphate ampoules are commercially available. They are not routinely held by all HNE Health sites. 1.3 Potassium replacement For the management of mild to moderate hypokalaemia, potassium supplements are to be given orally whenever possible. The following table provides guidance for potassium replacement. Guidelines for Potassium Replacement (oral and IV) Critical deficit Serum potassium < 2.0 mmol/l OR Serum potassium mmol/l and patient has severe acidosis ph < 7.2 (e.g. diabetic ketoacidosis) or severe cardiac disease or ECG changes of hypokalaemia Critical emergency Urgent specialist consultation is necessary. This may involve URGENT consultation with ICU, ED or the patient s physician for management advice Whilst initial treatment may be administered in ED or a ward setting, all patients should be transferred if necessary for appropriate ECG monitoring (e.g. in ICU or CCU) Severe deficit Serum potassium mmol/l (without critical conditions as described above and without ECG changes) Moderate deficit Serum potassium mmol/l Mild deficit Serum potassium mmol/l Carefully monitor fluid balance IV OR Oral replacement as follows Oral mmol potassium per day OR IV 40 mmol potassium per litre IV premix bag at maximum rate of 10 mmol per hour (250 ml per hour) or use 10 mmol potassium per 100 ml if available for fluid restricted patients. o Check potassium level every 6 hours o Repeat until serum potassium > 3.2 mmol/l If this fails to raise potassium levels over 24 hours, or potassium falls into critical range, contact treating consultant or ICU for advice. Oral (preferred) OR IV replacement. Oral mmol potassium per day OR IV 30 mmol potassium per litre IV premix bag at maximum rate of 10 mmol per hour (325 ml per hour) or use 10 mmol potassium per 100 ml if available for fluid restricted patients o Check potassium level every 24 hours o Repeat until serum potassium > 3.2 mmol/l If unsuccessful, use severe deficit guidelines (above) Oral mmol potassium per day Normal potassium requirement is approximately 1 mmol/kg/day Version Three April 2013 Page 4

5 1.4 Administration of intravenous potassium All potassium chloride solutions must be administered via an infusion pump. Concentrated potassium should only be added to a bag of infusion fluid if a premix solution is not clinically appropriate. Prior to preparing an infusion using concentrated potassium chloride CHECK with the prescriber if a premix IV bag is suitable (refer Appendix 1). If preparing an IV infusion by adding concentrated potassium injection (any salt form), the resultant solution should be mixed well. The bag must be fully inverted 10 times to ensure adequate mixing. Administration via a central line is preferable for hypertonic potassium solutions to prevent phlebitis and patient discomfort (prolonged administration of potassium solutions of > 40 mmol/l may cause phlebitis) therefore patients requiring high doses of potassium should be considered for a peripherally inserted central catheter (PICC) line or central IV access. NEVER add potassium to an IV bag that is already being infused. NEVER add extra potassium chloride concentrated injection to premixed solutions, as this may lead to confusion regarding the final concentration. For information on compatible fluids and medications, refer to the latest edition of the Australian Injectable Drugs Handbook, which should be available on all wards or via CIAP. Where fluid management is a problem or the concentration of potassium to be infused is greater than 40 mmol/l, then the premix IV bags of 10 mmol potassium chloride in 100 ml of 0.29 % of sodium chloride should be considered. These are safe to administer via a peripheral line as they are isotonic solutions. 2. CLINICAL INFORMATION TO ASSIST IN THE PREVENTION AND MANAGEMENT OF HYPOKALAEMIA The following information is intended to prompt a careful patient assessment and should be supplemented with advice from senior colleagues. The normal diet contains mmol of potassium chloride per day. Consider possible causes of ongoing loss: Route of Loss Urine Diuretics Alkalosis Gut (diarrhoea/vomiting) Pancreatic or small bowel fistula Amount of Potassium 20 mmol/l (minimum) mmol/l of urine mmol/l of urine 40 mmol/l of GIT loss 100 mmol/l of fluid loss The reference range for serum potassium is mmol/l. When serum potassium concentrations fall below 3 mmol/l, each 1 mmol/l decrement represents an additional mmol deficit in total body stores. These calculations should be used cautiously if intracellular potassium shifts account for the hypokalaemic state (usually due to ph abnormalities). Therefore, the plasma concentration of potassium should be monitored frequently when assessing the response to treatment. Version Three April 2013 Page 5

6 2.1 Prevention of Hypokalaemia Active medical procedures / problems which exclude oral potassium (nasogastric suction, complete bowel inactivity e.g. ileus) will induce hypokalaemia. The rate of development of hypokalaemia will be accelerated if there is concomitant use of an intravenous loop diuretic or the patient develops an alkalosis. Intravenous administration of 2 L (2000 ml) 4% glucose / 0.18 % saline + 20 mmol of potassium over 24 hours provides a minimum potassium supplementation as well as providing 80 g of glucose to decrease caloric deprivation. 2.2 Prevention of Hypokalaemia during the Management of Ketoacidosis The serum potassium is commonly elevated when a patient presents with ketoacidosis (diabetic or other cause). There is a major total body depletion of potassium despite the high serum potassium concentration. Insulin promotes the entry of potassium into skeletal muscle and hepatic cells and can cause a precipitous drop in serum potassium during insulin infusion therapy. Patients with ketoacidosis also have transient gastroparesis and the oral administration of potassium chloride (whilst the patient is acidotic) is very likely to be ineffective. Intravenous potassium supplementation should be commenced once the serum potassium falls to the upper limits of normal. The replacement rate is 5 to 10 mmol per hour. The following premix solutions can be used: 20 or 30 mmol/l potassium chloride in sodium chloride 0.9 % (normal saline) OR 40 mmol/l potassium chloride in sodium chloride 0.58 %, 1000mL bag. This product has been discontinued by Baxter, it will no longer be available to order once current supplies have been exhausted. The replacement product is AHK mmol/L potassium chloride in 0.9% sodium chloride, 1000mL. Hypokalaemia, if present at the time of presentation with ketoacidosis, demands management in a critical area ICU/HDU/CCU or other intensively staffed area and the involvement of an Intensivist, specialist or consultant experienced in more aggressive potassium replacement. While there is continuing change in ph status (common with the use of insulin infusions) the serum potassium should be checked at regular intervals (see JMO handbook for management of ketoacidosis). 2.3 Established Hypokalaemia Management of a problem demands an attempt to understand the cause and in most circumstances the aetiology is apparent: prolonged vomiting; profuse diarrhoea; excessive diuretic use aggravated by reduced oral intake of food and thus low potassium intake. Lower intestinal secretions are high in potassium and depletion of total body potassium is directly attributable to that mechanism vomited fluids are low in potassium and the major potassium loss is renal. The first step in management is to correct the obvious underlying mechanism. Version Three April 2013 Page 6

7 Oral replacement of potassium chloride is not applicable if vomiting/poor intake etc is not reversible. When diuretics/poor intake/dehydration can be quickly reversed, then oral replacement is safe and preferred. When the rate of correction of hypokalaemia is not critical, a high potassium diet will deliver 100 mmol potassium per day. Examples of available oral potassium supplements are: Slow release potassium chloride (Span K, Slow K ) 2 tablets every 6 hours gives an additional 64 mmol per 24 hours. Potassium chloride effervescent (Chlorvescent ) 1 tablet every 6 hours (dissolved in 100 ml water) delivers an extra 56 mmol per 24 hours. REFERENCES: 1. Burridge, N. (ed) Australian Injectable Drugs Handbook. 4th edition Melbourne: Society of Hospital Pharmacists of Australia. 2. Donohoo, E. (ed) EMIMs Potassium Chloride injection information. < accessed 02/2008> 3. HNEH 2006 Potassium Chloride: Safe Use Within Belmont Hospital Policy: Appendices: Appendix 1 Appendix 2 Potassium containing preparations available within HNE Health facilities Poster Potassium Chloride IV Preparations Version Three April 2013 Page 7

8 Appendix 1 Potassium containing preparations available within HNE Health facilities Oral potassium preparations Amount of potassium contained Potassium Chloride SR Tablets 600 mg (Span K, Slow K ) Potassium Chloride Effervescent (Chlorvescent ) Potassium Chloride Oral Mixture 8 mmol potassium per tablet 14 mmol potassium per tablet 20 mmol potassium / 15 ml solution PREMIX SOLUTIONS NB: NOT all of these premix solutions are available within each HNE Health facility Containing 10 mmol potassium CHECK first before prescribing 100 ml of sodium chloride 0.29 % NB: This solution is isotonic 500 ml of Sodium Chloride 0.45 % / Glucose 2.5 % 500 ml of Sodium Chloride % / Glucose 3.75 % Containing 20 mmol potassium 1 litre of sodium chloride 1 litre of glucose 4 % / sodium chloride 0.18 % 1 litre of glucose 5 % 1 litre of glucose 5 % / sodium chloride 0.45 % Containing 30 mmol potassium 1 litre of sodium chloride 0.9 % 1 litre of glucose 4 % / sodium chloride 0.18 % 1 litre of glucose 5 % 1 litre of Hartmann s Solution (compound sodium lactate) Containing 40 mmol potassium 1 litre of sodium chloride 0.58 % Discontinued March litre of sodium chloride 0.9 % NB: This solution is NOT isotonic 1 litre of glucose 4 % / sodium chloride 0.18 % Potassium Injections Concentrated Potassium chloride Amount of potassium contained in 10 ml Potassium Chloride (0.75 g) 10 mmol potassium per 10 ml ampoule NOT RECOMMENDED USE PREMIXED FLUIDS WHENEVER POSSIBLE Alternative concentrated potassium salts such as potassium acetate and potassium dihydrogen phosphate ampoules are commercially available. They are not routinely held by all HNE Health sites. If being used to replace phosphate, the rate of infusion is still governed by the potassium content. Consider using other phosphate salts or oral phosphate supplements. Version Three April 2013 Page 8

9 Appendix 2 Safe Handling of Adult Intravenous Potassium Chloride Preparations PD2005_342:PCP2 Potassium Chloride IV Preparations MEDICATION ALERT! Intravenous potassium can be fatal if given inappropriately. General rules / restrictions for concentrated potassium chloride ampoules If ampoules are kept in critical care areas, they MUST be stored securely, separated from other ampoules in an area labelled Hypertonic Solutions or similar. Sample Where there is an onsite Pharmacy Department ampoules MUST be obtained as an individual patient order, for non critical care areas. MUST BE DILUTED before administration. NEVER add to an IV bag that is already being infused. NEVER add extra to premix solutions. Prescribe a standard IV premix solution whenever possible Premix solutions (Please Note: NOT all of these premix solutions are available within each HNE Health facility. CHECK before prescribing) Containing 10 mmol potassium 100 ml of sodium chloride 0.29% [This solution is isotonic] 500 ml of Sodium Chloride 0.45% / Glucose 2.5% 500 ml of Sodium Chloride 0.225% / Glucose 3.75% Only Containing 30 mmol potassium Containing 20 mmol potassium 1 litre of sodium chloride 0.9% 1 litre of glucose 4% / sodium chloride 0.18% (Not recommend for use in children) 1 litre of glucose 5% 1 litre of glucose 5% / sodium chloride 0.45% 1 litre of sodium chloride 0.9% 1 litre of glucose 4% / sodium chloride 0.18% (Not recommend for use in children) 1 litre of glucose 5% 1 litre of Hartmann s Solution (compound sodium lactate) Containing 40 mmol potassium 1 litre of sodium chloride 0.58% [This solution is isotonic.] Discontinued March 2013, 1 litre of sodium chloride 0.9 % NB: This solution is NOT isotonic 1 litre of glucose 4 % / sodium chloride 0.18 % HNE Health PCP 2 Safe Handling of Adult Potassium Chloride in HNE Health Facilities NSW Health Policy Directive PD2005_342 Safe Handling of Intravenous Potassium Chloride in NSW Health Care Facilities Version Three April 2013 Page 9